HomeMy Public PortalAbout6031 & 6035 ENCINITA AVE_Mechanical__ rWQRKI:RS COMPENSATION DECLARATION APPLICATION IL PP0 P9 9V9 IC p TION FOR PERMIT
I hereby affirm that I hate a certificate of consent to self Ytl
insure, or a certlffca(te of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
CE-818(REV, 10/81) -
Policy No. Compony
Certified copy is hereby furnished. COUNTY OF LOS.ANGELES BUILDING AND SAFETY
❑ , Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING �/•-
tion department. (PRINT OR TYPE ONLY) ADDRESS es
�GS� C��i2L��
Date Applicant LOCALITY
- �.
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' _ NEAREST t,
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($I00)or less.)
AIR HANDLING UNIT,CFM l.f Ud
I certify that in the performance of the work f r which this [
permit is issued, I shall not employ any perso 'n any manner
so as to become subject to the Workers Dea5ati00 Laws. BOILER, BTU APPROVALS DATE PECTOR'S SIGNATURE
COMPRESSOR, BTU ROUGH- i r 7
Date ---Applic
NOTICE O APPLICANT: If, a e mak g th' Certificate of VENTILATION SYSTEM FINAL —�
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
.with comply with such provisions or this permit shall be '
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 / HEATER: SUSPENDED UNIT_ a'
.(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect. d
O
License Number Lic. Class -' D V
OC
Contractor Date O
H
F-1I am exempt under Sec. V
Plan check fee IL
m
B.BP.C. for this reasonW
N
Date: PERMIT ISSUING FEE $ a
Signature TOTAL FEE 5V
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason'(Section 7031.5, Business and NAME 4 9 2 8 A
Profeions Code):ss - -
L��1Q� ADDRESS e;e e e e 8
I, as.owner of the property, or my employees with
wages as their sole compensation,will do the work and CITY TEL. NO. I ° ° 2 Q 5 0
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNERe L 2 fi/Es 2 0.5 0 06
e e
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL0 Q 7 1 —8 6
tion 7044, Business and Professions Code). ADDRESS GT�V%' Gr
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for D
the performance of the work for which this permit is issued CONTRACTOR '
(Sec. 3097, Civ. C.). - - --
ADDRESS - -
Lender's Name
CITY TEL. NO. -
. Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS -
above information is correct. I agree to comply with all County
ordinances and State laws Iatin9 to building construction,
ond hereb authorize rgp' sentatives of this County to enter -
upon bove-men 6 d property for inspect' n.pUurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa Nr p imnt or gent ate